Past studies have established
relationships between smoking, and some anxiety disorders such as
post-traumatic stress disorder and panic disorder. Despite countless evidence
of the social nature of smoking, less attention has been paid to social
anxiety’s relationship with smoking, specifically poor cessation outcomes and
social anxiety disorder (SAD). This is an important aspect missing in the
literature given previous estimates that approximately 14–32% of individuals
with SAD are tobacco smokers (Morissette et al., 2007). Social learning theory
is the foundation to fully understanding the relationship between SAD, smoking
behaviors and poor cessation outcomes (Marlatt and Gordon, 1985). Social
learning theory explains that relapse to smoking occurs in response to
high-risk situations, including stressful emotional situations and social
situations that are perceived as stressful. Existing experiments found strong
reinforcement of the value of the drug, declining self-capability correlated
with poor cessation outcomes. (Tong et al., 2007). Comparing this to an undergraduate
sample of 38 regular smokers, SAD predicted smoking to cope with behaviors and
number of cigarettes that participants estimated they would need to smoke to
feel comfortable in social situations (Watson et al., 2012).

American Psychiatric Association states SAD as a constant fear of social or
performance based situations in which a person feels exposed to unfamiliar
people or to possible judgement by others based on their performance or
behavior (American Psychiatric Association, 2013). An individual who has a fear
that he or she will act in a way or show anxiety symptoms that will be
embarrassing and humiliating in a social setting are symptoms of SAD. An
important individual factor relevant to psychological-based smoking processes
and poor cessation outcomes is SAD. Although many existing experiments have
focused on the role of anxiety sensitivity (AS) in predicting future panic
attacks and other related forms of psychopathology, other studies suggest
persons with SAD, compared with those without a history of SAD, are more likely
to report elevated levels of AS. (Taylor, Koch, & McNally, 1992). This is
suggesting a possible relationship between SAD, AS, how both affect smoking
cessation outcomes and smoking behaviors (Schmidt, Lerew, & Joiner, 2000).
This relationship is important to understanding how SAD plays a role in AS
which is an established cognitive risk factor for all other anxiety disorders.

plays a specific and relevant role in psychological-based smoking processes and
their relation to AS and smoking cessation. The present studies suggest that
SAD may be more relevant to understanding AS and cessation-related
difficulties. This investigation seeks to examine specifically smoking
cessation difficulties, in the context of SAD, for perceptions of
cessation-related difficulties among adult treatment-seeking daily smokers. SAD
and AS are associated with lifetime heavy smoking behaviors, nicotine
dependence, and failed quit attempts (Cougle et al., 2010). Our study focuses
on SAD perceptions, beliefs, and their relationship in poor cessation outcomes.
SAD is relevant to the fact that smoking will reduce negative affect in social
situations, which in turn reduces cessation rates in smokers with SAD.

proposed study seeks to examine SAD relationship to perceived barriers of
quitting and establishing a significant correlation of increased cessation
difficulties for those with SAD. Those with higher SAD have higher perceived
barriers to cessation leading to cessation difficulties. Understanding how SAD
rates correlate with perceived barrier rates is important to understanding poor
cessation outcomes. SAD relationship with perceived barriers is a gap in the
literature that needs to be examined to fully understand anxiety related
cessation difficulties.

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One hundred heavy smokers with social
anxiety disorder and one hundred smokers without SAD are recruited through
advertisements in local newspapers, websites and community postings. To even
consider participants had to be 18 years or older and smoke a minimum of 20 or
more cigarettes daily for at least 2 years. Participants must provide an air carbon
monoxide breath sample of 12 ppm or higher on the first baseline sessions to
assure that all participants are heavy smokers. Upon second arrival
participants will also be administered a carbon monoxide breath sample to
assure participants are not smoking in the end unless failed cessation attempts
are marked down. In addition, participants had to meet full diagnostic criteria
for SAD. Participants taking psychotropic medications were also required to be
on a stable dose for at least four months that way reported symptoms were
unreflective of starting or stopping medications. Those left eligible completed
baseline self-report questionnaires and scheduled two experimental sessions,
each session being 30 minutes long and scheduled eight weeks apart. Participants
are recruited to participate in examining the effects of an eight-week session
of smoking cessation analysis that focuses on vulnerability to SAD.


For both sessions all participants will be
administered The Liebowitz social anxiety scale (LSAS); which is used to
measure participants levels of SAD (Liebowitz, 1987). In comparison, The
Barriers to Cessation Scale was used to assess struggles, stress
related/associated with smoking cessation and later to be compared to SAD
measure scores (Macnee & Talsma, 1995). People who scored the highest on
the LSAS and Barriers to Cessation Scale initially should report more failed
cessation attempts and a greater anxiety level upon the second session
examination. Smoking cessation elevates levels of SAD symptoms, which
corresponds with increased perceived barriers to smoking cessation. The
Liebowitz Social Anxiety Scale is composed of 24 items divided into 2
subscales, 13 concerning performance anxieties and 11 pertaining to social
situations. The 24 items are first rated on a Likert Scale from (0=None to
4=Severe) on fear felt during the situations, and then the same items are rated
regarding avoidance of the situation (0=never to 4=usually) which are both
symptoms of SAD (Liebowitz, 1987). This scale measures the amount to which
participants are concerned about possible negative consequences of SAD symptoms
and scenarios. LSAS was shown to have reliable psychometrics, the most
important finding was that people who showed one negative perception of a
social scenario also fell into other negative association categories. LSAS
shows sound psychometrics by a significant positive correlation observed
between the results of Beck Scale (Beck et. al, 1961) and Liebowitz Scale.
Software was used for statistical analysis in the diagnosis of social anxiety
and the scales’ relationship to one another. (Tyrala et. al, 2015). The
Barriers to Cessation Scale is a 19-item measure on which participants
indicate, on a Likert-type scale (0 = not a current barrier or not applicable
to 3 = large barrier), the amount to which participants identified with each of
the listed barriers to cessation such as a fear of failing to quit or fear of
never smoking again. Reliable psychometrics were shown through the BCS scale
and the Daily Hassles Scale. This was demonstrated by significant correlations
and similar findings between the scores of the BSC and scores of the Daily
Hassles Scale (DeLongis, Folkman, & Lazarus, 1988). An important finding
was that the way people process barriers to smoking heavily influences the
process of quitting.


Participants will
be given detailed description of the study over the phone and scheduled for an
appointment after responding to various community advertisements. Upon arrival
to the laboratory, each participant will be greeted by a research assistant and
provided verbal and written consent to participate in the research study. After
the initial sign up process, session participants will be administered nicotine
replacement therapy and be asked to stop smoking. Participants will then be scheduled
for a second session for eight weeks later, participants will be asked to
report failed cession attempts in this period and be administered both tests
upon second arrival. The participants will be paid fifty dollars and the two sessions
will be held in a quiet office space. For ethical standards participants will
be give nicotine replacement therapy and will be asked to call the office if
any concerns or reactions arise. Two groups are assigned to participants, one
group will be high anxiety scores and the other low anxiety scores. All scores
obtained will be from the initial test scores from first session participation
and this will determine their assignment. High anxiety group participants, will
have 12 or above severe scores and low anxiety level participants scored 11 or
less severe scores on both scales. Instructions will be given to participants
upon first session to stop smoking and keep a journal of how many failed
attempts they have in the next eight weeks if any. The sequence of what will
happen to participants is upon first session they will be administered the LSAS
scale and the BCS scale. As the participants are keeping track of their smoking
behaviors groups will be assigned to each participant with relation to their
scores on both scales. When placed into groups the participants will be administered
the scales and those who scored highest on both scales should report poor
cessation outcomes. Only one form of manipulation will be used which is
nicotine replacement therapy. Intervention will only happen if a participant
has sudden side effects from nicotine replacement therapy or emotional distress
from cessation attempts.


primary goal of the present research is to examine smoking behaviors amongst
those with SAD and the impact of SAD on perceived barriers to cessation. The
findings support the present hypothesis that those with higher SAD levels not
only showed lower cessation rates but also showed greater perceived barriers to
cessation. The present research indicates that smokers with SAD may benefit
from treatment for SAD while attempting smoking cessation. Pearson’s r and t
tests were used to test for possible group differences on smoking
behaviors, nicotine reinforcement and SAD. Pearson’s r correlations were used
to assess the extent to which the LSAS scale and the BCS scale correlated with
cessation outcomes. T test significance was found in high SAD participants with
high perceived barriers of cessation and poor cessation outcomes. Participants
without SAD showed better results for smoking cessation attempts and showed
less perceived barriers of smoking cessation. Possible reasons for inconsistencies
in this experiment could be that although SAD does play a role in smoking
processing and cessation outcomes, sampling could be a potential issue in this
experiment. The sample this experiment chose from was primarily a group of adult smokers who volunteered to
participate for financial compensation. To rule out potential selection bias among participants with
these characteristics and increase the generalizability of these findings, it
will be important for researchers to draw from other populations and apply
recruitment tactics other than those used in the present study.

            Overall, the present study offers notable insight into
the relationship of SAD, cessation outcomes, and perceived barriers to
cessation. Results suggest SAD is significantly related to cessation outcomes
and perceived barriers. Although current investigation found a relationship
between SAD and perceived smoking cessation barriers, future research needs to be
applied to fully understanding why there is a relationship between SAD and
smoking cessation. Future research can be used to assess which social situations
that trigger tendencies to smoke more than others. Understanding that SAD does
play a specific and relevant role in smoking cessation attempts, these findings
need to be used as a stepping stone to understand why SAD plays a role in
cessation outcomes. Numerous questions can be asked now that SAD is brought to
light as a factor in smoking cessation. Some questions that could be asked
after this investigation are, what social scenarios trigger SAD symptoms thus
leading to increased smoking urges? How relevant is SAD in cessation outcomes and
increased perceived barriers to smoking cessation? Understanding this
investigation was a frame work study which open doors for numerous future
investigation as to why SAD plays a key role in smoking processes.     


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